For families of children with life-threatening illnesses
Support    Advocacy    Research
 
Wednesday, 10 March 2010
Family Registration
If you have a child suffering from a severe, life-threatening condition and who is presently undergoing intensive treatment then you are warmly invited to identify yourself to us. You may not even need our support services, but in any event you will be making a valuable contribution to our research.
*Full Name of Child: *Age:
*Diagnosis:
*Approx Date of Diagnosis: (dd/mm/yy)
*Medical Consultant Name:
*Assigned Hospital Social Worker:
*Name of Hospital:
*Ward:
*Town/City:
*State:
Country:
*Your Full Name:
*Your Relationship to Child:
*Total Number of Chidlren
in your household:
*Your Email:
*Daytime Telephone:
Alt Telephone:

Please briefly describe your family's current situation below, ie: prognosis; employment; schooling; travel; accommodation, etc..
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